In a recent Progress blog Andy Burnham set out how, under Labour, the NHS would provide a single service for the whole person, meeting physical, mental and social needs together. Ed Miliband, in his Hugo Young lecture, committed Labour to a radical reshaping of services so that local communities can come together and make the decisions that matter to them.
Whole person healthcare and bringing communities together are inextricably linked: indeed, some 60% of the beneficial impact on health is accounted for by the ‘social determinants’, such as jobs, housing, education, lifestyle and local conditions. All the other services – local authorities, education, housing, employment, welfare, culture and sport – make a contribution to health as a spinoff from their own actions and responsibilities.
What people do for themselves and each other in their families, households, communities and networks is also a key factor in health. Some of this is entirely personal. Some of it forms the texture of shared community life – social clubs, sports activities, choirs, mother and toddler groups, bingo, even simply keeping up with friends.
Taking part in ‘local social action’ has many benefits for health, improving individuals’ resilience, supporting behaviour change such as stopping smoking, and overall helps to narrow health inequalities. There is a 50% increased likelihood of survival for people with stronger social relationships. This is consistent across age, sex and cause of death. It is comparable with tackling factors such as smoking, alcohol, BMI and physical activity[1].
Put simply: by increasing social networks, we improve health – and can hold public services to account. There is a deep connection between the density of social networks and the capacity of residents to respond, intervene and cooperate with official institutions. Making these networks denser will bring benefits to people and is likely to ease pressures on the health service.
Here is an example:
Building on the work of C2 (2), The Health Empowerment Leverage Project carried out a project in Townstal, Devon. A resident-led partnership brought police, dental services, play services and housing together. Within six months there was an increase in satisfaction with services, and police reported crime dropping as a result of the partnership. New groups began, serving local needs, and attracting funding from outside the area for new projects (www.healthempowerment.co.uk). The continuing life of the resident-led partnership can be seen at www.townstalcommunitypartnership.org.uk .
Results included a new dental service established, a playpark established and fully used, a new GP surgery planned and well-attended social events and football sessions.
Health agencies must understand social networks and the cumulative effect of all the public and private services which impact on a given locality. For far too long, they have pursued community involvement in a marginal way and in isolation from the very people and agencies whose collaboration they need. This has been self-defeating, missing huge opportunities to boost the benign social determinants.
Empowering citizens and communities does not happen by simply letting go of the reins but by making local empowerment part of the universal system. This means also incorporating it as a requirement even where a service is being delivered by the private or voluntary sector. Empowering local communities and collaborating with other services needs to be part of every commissioned contract. The citizen powers we want to boost are not powers that compete with the system but powers to make it work at its best.
The tragedy of declining support to community activity – completely unmonitored by the Coalition government – is doubly frustrating because the resources that are needed are marginal compared with those of the mainstream services. Funding is needed for community development workers, training, leadership, and time spent by staff in partnership activities with communities and partner agencies. An investment of £2m in each principal local authority area in England (about £300m in all), which could hugely increase local community activity if it were well planned, would amount to less than 0.3% of the health budget. Pilot studies by the HELP group suggest returns of at least 6:1.To avoid a postcode lottery, it has to be made clear that the rights and the responsibilities outlined in the NHS Constitution and in other legal requirements ensure clear national deliverables which cannot be gainsaid locally. However, how these national commitments are delivered needs to be open to influence at local level. We need a combination of central requirements and local participation and responsiveness.
If we are to make prevention a reality, such upfront investment is a necessity. This needs to be driven forward. It will make the job of health agencies easier, not harder. Localities will have scope to do it their own way because every locality is different, but we will expect a clear direction of travel in each locality towards addressing the social determinants on a broad front through cooperation with other public services and with local communities.
[1] Social relationships and mortality risk: a meta-analytic review. Holt-Lunstadt, Smith, Bradley Layton. Plos Medicine, July 2010, Vol 7, Issue 7.
[2] Durie R, Wyatt K, Stuteley H. Community Regeneration and Complexity ’Complexity and Healthcare Organization ‘a view from the street’ March 2004 – Radcliffe Medical Press
First published by Progress